Vet Mgmt- Midterm- Medical Records

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Author:
jenafer
ID:
113248
Filename:
Vet Mgmt- Midterm- Medical Records
Updated:
2011-10-30 22:33:15
Tags:
medical records veterinary
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Description:
medical records
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  1. a brief and complete record on each individual animal
    a medical record
  2. we need ___ to provide better care of the patient through thorough recording of every detail regarding case.
    medical records
  3. medical records provide for recording of all diagnostic data to establish ___
    diagnosis
  4. exists as a legal contract for care of patient and collection of fee
    medical record
  5. ___ is necessary for income and sale tax documentation
    medical record
  6. a ___ must be documented upon performance of task, or written daily
    record
  7. what is a visible record of what the hospital is accomplishing
    medical records
  8. having a ___ medical record system saves time and money
    computerized
  9. a medical record system that will calculate estimates, invoices for you and perform grammar and spell checks on your notes
    computerized medical record system
  10. Dr. Grey did a radiograph of Fitos leg. Who owns this record
    all medical records are owned by the veterinary practice
  11. all medical records must be kept for ___ years
    3
  12. when you make a mistake on a medical record, you are not permitted to use _a_, instead you must _b_ your mistake with a _c_ and leave your _d_ beside it
    • a. white-out
    • b. cross out
    • c. single line
    • d. initials
  13. if you had to correct an error on a medical record and now you want to put in the appropriate notes, you must first ____ before you make an entry
    skip a line
  14. If Fitos pet parent wants a copy of her dogs radiograph she is...
    entitled a copy at a "reasonable fee"
  15. what is an acceptable request for medical records to be send to another veterinary hospital
    a written request signed by the client, or a fax or email with the clients signature.
  16. 3 ways how medical records are a form of proof against malpractice suits
    • 1. proves against negligence, fraud, or imcompetence
    • 2. proves compliance with administration of controlled substance and medications
    • 3. proves the existence of a vet/client/ pet relationship
  17. medical records on controlled substances and medications must be kept for _a_ years from the date _b_
    • a. 5
    • b. used
  18. where are vets required to have licenses to keep animals in their custody
    NY and CA
  19. Every animal in vets custody needs a record called ___
    SOAP
  20. SOAP means ...
    • subjective
    • objective
    • assessment
    • plan
  21. a diagram that may be downloaded or drawn and put into a record
    anatomical models
  22. what needs to be updated each time a pateint visits and each time shifts change
    a physical examination
  23. name things that should be on medical records
    • patients history
    • vacc status
    • physical examination
    • symptoms
    • diagnosis
    • prognosis
    • biopsy or necropsy reports
    • client education (at home care)
    • client authorization for patients treatment
    • discharge summary
    • fee estimate
  24. what should be separate from medical records and not readily available to all employees
    financial info (credit card, cash, check)
  25. medical records also require pet parents info ...
    • 1. pet parents pet
    • 2. street address
    • 3. city and zip code
    • 6. home and cell number
    • 7. spouse name and number
  26. medical records require pets identification info such as ...
    • 1. name
    • 2. species
    • 3. breed
    • 4. sex
    • 5. description
    • 6. vaccine record
    • 7. medication allergies
  27. what is hardware
    touchable parts of the system
  28. what tells parts of the hardware how to communicate
    operating system
  29. what helps users to perform specific tasks
    application software
  30. what manages network, the back up server, and connects all terminals together.
    server
  31. taking an animals history means documenting any changes in ...
    • 1. diet
    • 2. lifestyle
    • 3. app & activity
    • 4. Vx
    • 5. PPh
    • 6. C/S
    • 7. V/D
    • 8. Pu/PD
    • 9. weight
    • 10. personality
  32. ___ refers to any condition resulting from diet change, access to garbage, toxins, appearance of blood or mucous.
    • V/D
    • vomiting/ diarrhea
  33. ___ refers to any condition resulting in pruritic, seasonal, contact withother animals or new bedding/ carpet, etc
    integument
  34. ___ refers to any condition resulting in Pu/Pd, pollakiuia, dysuria, stanguria, dribbling, leaking, hematuria
    urinary
  35. ___ refers to any condition resulting in dry or moist cough, or cough during activity, or night time
    CV
  36. ___ refers to a condition resulting to gradual of sudden trauma after exercise affecting one or more limbs, etc
    MS
  37. Order of which we examine. example: The ear

    • 1. check external parts (the pinna)
    • 2. check internal parts with an otoscope (the inner ear)
  38. the observance of symmetry, attitude, gait, body condition
    distance examination
  39. the observance of ocular, optic, oral, lesions, CRT, odor, coat and skin
    close-up examination
  40. feeling for lumps/bumps, abscesses, hematomas, cysts, ascites, CN
    palpation
  41. listening for sinuses, in the trachea, thorax and the abdomen
    auscultation
  42. #1 rule of doing a physical exam
    always examine the patient from the very tip of their nose to the very tip of the tail. do not by-pass any parts
  43. a radiology log is recorded because we want to know 2 things
    • 1. how often the radiograph is used
    • 2. how often we need to do maintenance repairs
  44. a radiology log would contain what information
    • 1. exam date
    • 2. type performed
    • 3. pet parents name
    • 4. animals name
    • 5. case number
    • 6. exposures
    • 7. dvm's name
  45. every patient undergoing anesthesia must have notations in log containing _a_, _b_, and the _c_.

    vitals must be noted every _d_
    • a. pre-med drugs
    • b. induction
    • c. amount used
    • d. 15 minutes
  46. a log kept for tissues sent for histopathology, date, owners name, animals name, species, an tissue type
    biopsy log
  47. a log kept for deceased animal tissues that will be thoroughly examined
    necropsy log
  48. what info is required on a necropsy log
    animals name, owners name, species, date, the tissues submitted, and the DVM performing
  49. which log inst required but kept to know when to bill clients
    necropsy and biopsy logs
  50. BAR stands for
    bright alert responsive
  51. QAR
    quiet alert responsive
  52. H&L
    heart and lungs
  53. WNL
    within normal limits
  54. NSF
    no significant findings
  55. NPR
    no pupil response
  56. EENT
    ears eyes nose throat
  57. DDZ
    dental dz
  58. ENT
    ears nose throat
  59. PLN
    peripheral lymph nodes
  60. OHE
    ovario hysterectomy
  61. CHF
    congestive heart failure
  62. H
    hydrated
  63. SO or E&D
    sign/ euthanasia, euthanasia & disposal
  64. C
    coughing
  65. S
    sneezing
  66. C/S
    coughing and sneezing
  67. V
    vomiting
  68. D
    diarrhea
  69. V/D
    vomiting and diarrhea
  70. MM
    mucus membranes
  71. CC
    cheif complaint
  72. HX
    history
  73. RX
    treatment/prescription
  74. FX
    fracture
  75. T
    temperature
  76. SQ
    subcutaneous
  77. FF
    force feed
  78. PO
    per os
  79. NPO
    nothing per os
  80. OU
    both eyes
  81. OD
    right eye
  82. OS
    left eye
  83. OO
    ophthalmic ointment
  84. AU
    both ears
  85. AD
    right ear
  86. AS
    left ear
  87. HP
    hot pack
  88. P
    pulse
  89. R
    respiration
  90. TPR
    temperature pulse respiration
  91. q 6 hr
    every 6 hrs
  92. sid
    once daily
  93. bid
    twice daily
  94. tid
    three times daily
  95. qid
    four times daily
  96. eod
    every other day
  97. PCV/ Hct
    packed cell volume
  98. CVP
    central venous pressure
  99. C-
    with
  100. QNS
    quantity not sufficient
  101. HGE
    hemorrhagic gastroenteritis
  102. Et
    Etiology
  103. Sig
    instruction
  104. RACL
    ruptured anterior cruciate ligament
  105. PPHx
    past pertinent history
  106. PH
    perineal hernia
  107. CDI
    clear, dry, intact (refering to an incision)
  108. MI
    mitral insufficiency
  109. TTTP
    too tense to palpate
  110. SM
    systolic murmur
  111. SR
    suture removal
  112. UG
    urogenital
  113. MS
    musculoskeletal
  114. X
    express
  115. ( arrow pointing up)
    increase
  116. (arrow poining down)
    decrease
  117. (check)
    checked
  118. mcg
    microgram
  119. mg
    milligram
  120. ml
    milliliter
  121. Gr
    gram or grain
  122. FeLV
    feline leukemia virus
  123. SMA
    blood biochemistry
  124. WBC
    white blood cells
  125. RBC
    red blood cells
  126. Diff
    differential count
  127. R/O
    rule out
  128. D/C
    discontinued
  129. APP
    appetite
  130. PRN
    as needed
  131. IV
    intravenous
  132. IM
    intramuscular
  133. SQ
    subcutaneous
  134. 3 reasons for restraint
    • 1. control of a procedure (minimum restraint)
    • 2. to prevent animal for hurting itself
    • 3. to protect yourself
  135. true or false
    a client may restrain their pet if needed
    false. clients never restrain their pets!
  136. three types of restraints
    • 1. verbal
    • 2. physical
    • 3. chemical
  137. name some physical restrainers
    • leashes
    • muzzles
    • ropes
    • rabies pole
    • blankets and towels
    • minimal collars
  138. name some chemical restrainers
    • 1. dexDomitor
    • 2. benzodiazepines IM
  139. how do you decide what restraint is appropriate
    judge what type of procedure it is and how much restraint is necessary
  140. OSHA laws
    • 1. blood-bourne pathogen law
    • 2. hazard communication law
    • 3. safety requirements in general industry
    • 4. general duty clause
  141. law that states that "every facility must be safe for every employee"
    general duty clause
  142. requires that each employee have an individual training folder which documents all OSHA training, on-going training, and must be continuously updated and kept 3 years after employee has left
    general duty clause
  143. requires that each employee have a confidential medical folder that contains document proof of vaccinations or in the event that they decline the vaccine.
    general duty clause
  144. requires personal medical files containing pre existing conditions such as medications, blood type, and anything else useful in an event that the employee has an emergency
    general duty clause
  145. if you feel you arent protected from hazards in the workplace, it is the employees right, from their employer, to recieve:
    • 1. training on chemicals and other on-the-job hazards
    • 2. OSHA worker standards info on injuries, illnesses, hazards, and workers rights
    • 3. request action to correct hazards or violations
    • 4. file a complaint with OSHA
    • 5. be involved with OSHA's inspection there
    • 6. find out OSHA's conclusion
    • 7. request a research investigation on possible workplace health hazards

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